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i <br /> San Joaqu#n Co. HHW <br /> 7850 South R.A. l3ndgeford St <br /> a�5 Stockton, CA 95206 <br /> No% Telephone(209)468-5670 <br /> MWANUMMIM SERM" Fax.-(209)468-5672 <br /> INVOICE 1 AUTHORIZATION FOR CREDIT CARD BILLING <br /> Date: 312512010 <br /> To: Clean Harbors Environments!Service Ju r#: 6,!2770981 <br /> Fax: <br /> Phona3 '(81-792-52149 <br /> From: Name: Dave Carmichael Acoount Number-, <br /> C222E2ny: Allied Waste _ Teahorse: 209-547-7524 <br /> mailing Address: 1145 West Garter Way Fax: 0 <br /> Citi 1 State: Stockton Ca 95206 <br /> This is authorization to pay the following Clean Harbors invoices: <br /> Invoice Number Elate Amount Invoice Number Date Amount <br /> Sjc 3126110 $298.40 <br /> ToUl Charges to be applied to credit card will be for the following amount $298.40 <br /> <br /> PIN#: CHECK# <br /> If yes, what is the aunt?$ <br /> Blame as it appears on Carni: Dave W Camicheal <br /> Company dame: <br /> Card Billing Address: 1145 West Charter Way <br /> Stockton Ca 95206 <br /> Credit Card Numbec 4807 1000 5062 5875 <br /> Card Authorization Date: j ov <br /> ( f <br /> Authorization Signature: t - <br /> RETURN RECEIPT BY: FAX 0 U.S. MAIL <br /> 1145 West Chanter Way <br /> Stockton Ca 95205 <br />